The Department of Defense Birth Defects Registry: overview of a new surveillance system.

BACKGROUND: The U.S. Department of Defense (DoD) is challenged with monitoring and protecting the health and wellbeing of its service members. The growing number of women on active duty and the diverse hazardous exposures associated with military service make reproductive health issues a special concern of DoD. To address this concern, the DoD Birth Defects Registry was established at the DoD Center for Deployment Health Research located at the Naval Health Research Center, San Diego, California. METHODS: The registry captures comprehensive data on healthcare utilization to calculate the prevalence of birth defects in the children of military beneficiaries. Population-based electronic surveillance is supplemented by active case validation efforts. RESULTS: Since its establishment in 1998, the registry has captured data on more than 90,000 births that occur in military families each year. Detailed analyses, to include linking registry data with military occupational exposure data (e.g., anthrax vaccination), are underway. CONCLUSIONS: The DoD Birth Defects Registry provides important reproductive health information on the geographically dispersed military population. This program is expected to complement civilian public health programs and be especially valuable to military members and their families.

Deep dermatophytosis: report of 2 cases and review of the literature.

Skin infections due to dermatophytes are common and generally associated with a low degree of morbidity in normal hosts. Rare cases have been reported in which the dermatophyte invaded the deep dermis, subcutis, or even internal organs. Two patients, each of whom had clinical and histological findings of a deep or locally invasive dermatophyte infection, are described. This condition typically presents as a nodular eruption that is characterized histologically by suppurative granulomatous inflammation and deposition of organisms in the reticular dermis. Recognition of the potential of dermatophytes for local invasion in susceptible hosts will help ensure proper diagnosis and timely intervention in these cases.

Cotyledonoid leiomyoma of the uterus: report of a case.

A 46-year-old woman presented with a pelvic mass. At the time of operation a large, exophytic, multinodular tumor extended into the peritoneal cavity and right broad ligament from a pedunculated attachment to the uterus in the region of the right cornu. On external examination the lesion had the appearance of cotyledonoid dissecting leiomyoma. On microscopic examination bulbous processes were composed of benign smooth muscle arranged in interlacing fascicles or swirls; there was focal hydropic degeneration. Significant nuclear atypia, mitotic activity, and coagulative tumor necrosis were not encountered. No intravascular involvement was present. There was no demonstrable parent leiomyoma or intramural dissecting component, and thus the case differed from previously reported cases of both cotyledonoid dissecting leiomyoma and intramural dissecting leiomyoma. This tumor represents another variation in the group of benign uterine smooth muscle tumors with unusual growth patterns.

Minimal deviation melanoma. Borderline and intermediate melanocytic neoplasia.

In the concept of MDM, the term melanoma has been reserved for lesions showing a vertical growth component. Vertical growth, divorced from any prognostic implications, is simply a morphologic designation. Such a maneuver also serves to validate the category of MDM, although it might then be inappropriate to characterize such lesions as melanoma. From my view, the modifier "minimal deviation" takes the onus of prognosis out of the equation. For common melanomas, size of a vertical growth component has relativity to prognosis. It is unlikely that, in comparable size-ranges, the MDM have a more aggressive nature than the common melanoma. It seems appropriate to propose that MDM measuring less than 1.5 mm in vertical dimensions could be characterized as melanocytic neoplasia of indeterminant malignant potential. Those less than 1 mm in vertical dimensions would be borderline variants and those in the range of 1 to 1.5 mm would be intermediate examples. Those greater than 1.5 mm could be characterized as melanocytic neoplasias of indeterminant (uncertain) malignant potential without additional qualifications.

Risk factors for mental disorder hospitalization after the Persian Gulf War: U.S. Armed Forces, June 1, 1991-September 30, 1993.

Effects of Persian Gulf War (August 2, 1990-July 31, 1991) and Gulf War occupation on post-War hospitalization risk were evaluated through Cox proportional hazards modeling. Active-duty men (n = 1,775,236) and women (n = 209,760) in the Army, Air Force, Navy, and Marine Corps had 30,539 initial postwar hospitalizations for mental disorders between June 1, 1991 and September 30, 1993. Principal diagnoses in the Defense Manpower Data Center hospitalization database were grouped into 10 categories of ICD-9-CM codes. Gulf War service was associated with significantly greater risk for acute reactions to stress and lower risk for personality disorders and adjustment reactions among men. Personnel who served in ground war support occupations (men and women) were at greater risk for postwar drug-related disorders. Men who served in ground war combat occupations were at higher risk for alcohol-related disorders. Longitudinal studies of health, hospitalization, and exposure beginning at recruitment, are needed to better understand how exposure to combat affects the mental health of military personnel.

Dissecting leiomyomas of the uterus other than cotyledonoid dissecting leiomyomas: a report of eight cases.

We report eight cases of benign uterine smooth muscle neoplasms with unusual growth patterns and intramural dissection. All the patients in our series were of reproductive age or perimenopausal (range, 36-51 years) and had an enlarged uterus or a pelvic mass, with the exception of one lesion that was found incidentally in a patient treated for uterine prolapse. Three also had abnormal uterine bleeding. On gross examination, the lesions had an unusual appearance and were often lobulated and irregular with indistinct margins. On microscopic examination of all the lesions in this study, a dominant benign smooth muscle tumor was associated with intramural dissection of the myometrium by fascicles of neoplastic smooth muscle. Of the eight cases showing intramural dissection, four were intramural dissecting leiomyomas; three were examples of intravenous leiomyomatosis; and one was a multinodular leiomyoma with hydropic degeneration. We excluded cotyledonoid dissecting leiomyomas from the study. In two of the three cases of intravenous leiomyomatosis, extrauterine extensions in continuity with the intramural components were noted at surgery and on gross examination. Intramural dissection of the myometrium by a benign smooth muscle tumor is one additional possibility to be considered in the differential diagnosis of leiomyosarcoma and low-grade stromal sarcoma.

Dimensionalities: borderline and intermediate melanocytic neoplasia.

The concept of minimal deviation melanoma is presented in diagrammatic form. In this approach, the precursors of melanoma are presented as having two dimensions and melanomas as having three dimensions. In turn, the relativity between dimensionalities and recommendations for treatment (as indirect correlates of prognostications) provides guidelines for the structuring of two major boundaries along the axis of the diagram. Finally, the domains defined by the two boundaries include borderline lesions, intermediate lesions, and "real melanomas." The lesions in the borderline and intermediate categories qualify as melanocytic neoplasias of indeterminant malignant potential; in these two categories, the predictability of metastases hardly justifies the use of the designation, malignant melanoma.

Lupus erythematosus-like features in patients with cutaneous T-cell lymphoma.

BACKGROUND: The development of lupus erythematosus-like (LE-like) features in patients with cutaneous T-cell lymphoma (CTCL) has not been reported previously in the literature. Both diseases, however, have been etiologically linked to retroviruses. OBJECTIVE: Our purpose was to report four cases of patients with CTCL who developed LE-like features during the course of their disease, and to evaluate for evidence of antibodies to retroviruses in the sera of these patients. PATIENTS: Four patients with biopsy-proven CTCL with clinical or histologic features of systemic lupus erythematosus (SLE) were evaluated for clinical and laboratory criteria for SLE. Only one patient demonstrated four American Rheumatism Association (ARA) criteria sufficient for the diagnosis of SLE. The remaining three patients demonstrated one or two criteria for SLE. In addition, the sera of these patients were examined by Western blot analysis for evidence of human immunodeficiency virus type I (HIV-I), human T-cell lymphotrophic virus type I (HTLV-I), or human intracisternal A-type particle type I (HIAP-I) retroviral proteins. Each patient demonstrated antibodies to some of the retroviral proteins examined. The sera of two patients reacted to proteins for HIAP-I, and the sera of two patients reacted to p24 gag proteins of HIV-I. No patient reacted to HTLV-I proteins. CONCLUSIONS: Our report identifies four patients with CTCL who developed LE-like features during the course of their disease. Although the etiology of CTCL and SLE has not been well established, each has been linked to retroviruses. Evidence of antibodies to retroviral proteins was identified in each of our patients by Western blot analysis. Although the clinical and laboratory findings in these cases do not resolve the etiologic role of retroviruses in CTCL or SLE, they suggest that retroviruses may have a role in the pathogenesis of the clinical phenomenon reported in these four patients.

The field hospital at Zagreb: tri-service medical care in a peacekeeping operation.

The objective of this investigation was to provide military medical planners with insights into the specific materiel, skills, and information requirements demanded by humanitarian missions through review of approximately 16,000 records from a tri-service medical patient database used at the field hospital in Zagreb, Croatia, during Operation Provide Promise. This review describes (1) the origin, rationale, structure, and implementation of the database; (2) the patients who used medical services provided by the hospital; (3) the diagnoses encountered in outpatient visits, admissions, and surgical operations; and (4) the distribution of medical services used by various subgroups of interest.

Variants of melanoma.

The current classification of malignant melanomas gives recognition to superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma, and nodular types. In addition, neurotropic and desmoplastic types are recognized. The relativity inherent in the diagnosis of melanoma, provides the basis for the classification of melanomas on the basis of size. Lesions measuring 1 mm or less in vertical dimensions are unlikely to metastasize; they qualify as borderline melanocytic neoplasia of indeterminant malignant potential. The current classification has little relevancy to the category of variant nevi with the exceptions of malignant cellular blue nevus and melanoma arising in giant congenital nevi. A classification of variant melanomas as related to variant nevi is proposed. From a different perspective, a classification of melanomas with attention to nesting and cytological patterns in vertical growth is proposed: this alternate approach gives recognition to lesions that might otherwise be classified as "nevoid" melanomas. It also provides a default category for lesions that might otherwise be assigned to the Spitz nevus-like category. All of these tools for the manipulation of the real and virtual images of melanomas have been emphasized in the concept of minimal deviation melanoma.

Cotyledonoid dissecting leiomyoma of the uterus. The Sternberg tumor.

We report four cases of an unusual uterine smooth muscle neoplasm. All patients were of reproductive age, ranging from 23 to 41 years old, and had a pelvic mass or an enlarged uterus. Two also had menstrual irregularities. At laparotomy, an exophytic congested bulky tumor resembling placental tissue extended from the uterine wall into the broad ligament and pelvic cavity. In one case the tumors were bilateral but unequal in size. On gross examination, these exophytic components were the most distinctive feature. On microscopic examination the basic lesion appeared to be a dissecting leiomyoma with growth at its periphery in sinuous dissecting patterns and extensive degenerative changes. Some microscopic features, including dissecting growth patterns, distinctive connective tissue alterations, and a rich component of vessels, overlap with those seen in several leiomyoma variants, including infiltrating leiomyoma, leiomyoma with perinodular hydropic degeneration, and intravenous leiomyomatosis. An intravascular component was not a feature. The distinctive gross appearance and microscopic features are embodied in the designation, "cotyledonoid dissecting leiomyoma." The follow-up information available for three cases supports the benign nature of the tumor.

Single photon emission computed tomography with iodoamphetamine-123 and neuropsychological studies in long-term abstinent alcoholics.

Ten long-term abstinent alcoholics (mean abstinence = 7.7 years) were compared with 13 recently detoxified substance-dependent inpatients (mean abstinence = 25 days) and 8 nonalcoholic control subjects on global end regional measures of cortical cerebral blood flow (CBF), and on neuropsychological measures. CBF was assessed using 123iodoamphetamine (IMP) single photon emission computed tomography (SPECT) under conditions of behavioral challenge (Raven's Progressive Matrices). CBF and neuropsychological test performance were worse in the recently detoxified inpatients. Of greater interest, there was a dissociation in the long-term abstinent group, which, while neuropsychologically indistinguishable from controls, showed significantly decreased mean cortical IMP uptake. We conclude that there may be persistent physiologic abnormalities in long-term abstinent alcoholics who have achieved full behavioral recovery. Smoking on the day of SPECT scanning was also identified to be a significant confound to understanding CBF changes in alcoholism.

Epithelioid glomus tumor.

Reported are five cases of an unusual histological variant of glomus tumor that we have designated epithelioid glomus tumor. Unlike conventional glomus tumors, which consist of small polygonal cells with dark round nuclei and scanty cytoplasm, the epithelioid lesions were composed of large polygonal to spindle-shaped cells with abundant eosinophilic cytoplasm and large, irregularly shaped nuclei: The cells had both epithelioid and myoid qualities. Two of the cases studied were predominantly epithelioid, with small remnants of conventional glomus tumor at the periphery. The three other lesions were purely epithelioid. Epithelioid glomus tumors are of particular importance because they may be mistaken for other lesions histologically. Both benign and malignant epithelial lesions may be considered in the differential diagnosis; spindle-cell lesions, such as schwannoma, leiomyoma, hemangiopericytoma, and others, are in the histological differential diagnosis. Immunohistochemical and ultrastructural studies indicated that epithelioid glomus tumors had characteristics identical to those of conventional glomus tumors: the cells showed features consistent with smooth muscle derivation. The epithelioid areas frequently exhibited cytological atypicality--features that we believe to be a manifestation of cellular degeneration or senescence (analogous to "ancient" change in schwannomas or symplastic change in leiomyomas) rather than evidence of neoplastic progression. Simple surgical excision seems to have been curative (mean duration of follow-up of 4 years in the three cases in which such information was available). To our knowledge, no similar cases have previously been reported.

Multilocular renal cyst (cystic nephroma) with müllerian-like stroma.

Multilocular renal cyst is an uncommon lesion of controversial histogenesis. The authors report a case of renal multilocular cyst with müllerian (ovarian)-like stroma. We suggest that this finding would support a dysontogenetic origin for the lesion.

Autologous collagen? Lipocytic dermal augmentation. A histopathologic study.

BACKGROUND: Soft tissue augmentation with processed fat has been used clinically for several years. This material has been termed "autologous collagen" since it was presumed it was composed primarily of collagen and fibrous tissue from lipocyte cell walls. OBJECTIVE: To examine the histologic behavior of dermis implanted with processed fat. METHOD: Volunteers were injected with processed fat intradermally in the post auricular area and these sites were biopsied at one week, one month, and three months. RESULTS: Early biopsies revealed no intact adiopocytes but a significant inflammatory infiltrate. Subsequently biopsies revealed replacement of the inflammatory reaction with cellular fibrosis and expansion of the dermis. CONCLUSION: Intradermal injection of processed fat results in deposition of fibrous material and collagen due to the response of the recipient site. The material itself contains very little collagen.